Special Types ApplicationPolicy Term From: To

1. Name (and "dba") Individual/Proprietorship Partnership Corporation Other Business Phone Number

2. Mailing Address City State Zip 3. Premises Address City State Zip

4. Person to contact for inspection (name and phone number) 5. Have you ever had insurance with one of the companies listed at the top of this page? Yes No

If yes, Policy Number(s) Effective Date(s)

DESCRIPTION OF OPERATIONS6. Describe business

Years experience New Venture? Yes No

7. Is this your primary business? Yes No If no, explain

Is your business seasonal? Yes No Is your business for hire/for profit? Yes No

8. Have you ever filed for Bankruptcy? Yes No If yes, when Explain

9. Gross receipts last year Estimate for coming year Business for sale? Yes No

10. Do you operate in more than one state? Yes No If yes, list states 11. What is the largest city entered within your radius of operation?

LIABILITY COVERAGE C Complete for desired coverages by indicating limits of insurance.LIABILITY

Split Limits Bodily Injury Property DamageCombined Single

Limit BI & PD Each Person Each Accident Each Accident

Medical Payments

Personal InjuryProtection

(where applicable)

IF PHYSICAL DAMAGE COVERAGE DESIRED - REFER TO FOLLOWING PAGE.

COMPLETE HIRED AND NON-OWNED SUPPLEMENT IF COVERAGE DESIRED.

APPLICABLE PERSONAL INJURY PROTECTION, UNINSURED AND/OR UNDERINSURED MOTORISTS INSURANCE SELECTION/REJECTION PAGE IS REQUIRED TO BE COMPLETED AND

SIGNED BY THE NAMED INSURED WITH THE SUBMISSION OF THIS APPLICATION.

DRIVER INFORMATION C If additional space is needed, attach separate listing.Driver's Licenses Experience

Driver's Name Date of Birth State Number Class/Type

(i.e. CDL) Years

Licensed (in Class/Type)

Type of Unit (Bus, Van,

etc.) No. of Years

1.

2.

3.

4.

5.

Accidents and Minor Moving Traffic Violations in Past 5 Years

Major Convictions (DWI/DUI, Hit & Run, Manslaughter, Reckless,

Driving While Suspended/ Revoked, Speed Contest, other felony)

No. Years Previous

Commercial Driving

Experience

Date of Hire No. of

Accidents Date(s) No. of Violations Date(s) Describe Conviction Date(s)

Employee (E) Ind. Cont. (IC)

Owner/Op. (O/O)Franchisee (F)

PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.

8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401

www.royaloakunderwriters.com

ROYAL OAK UNDERWRITERS, INC.Excess and Surplus Lines Insurance Wholesalers

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12. Does applicant have attendant's E&O coverage? Yes No 13. What is the basis for driver(s) pay? Hourly Trip Mileage Other, explain 14. Are drivers covered by Workers Compensation? Yes No Minimum years driving experience required 15. Are vehicles owner-driven only? Yes No Do you agree to report all newly hired operators? Yes No 16. Are drivers ever allowed to take vehicles home at night? Yes No If yes, will family members drive? Yes No 17. Do you order MVR's on all drivers prior to hiring? Yes No Driver's maximum driving hours daily weekly

SCHEDULE OF AUTOS/VEHICLES C Describe all vehicles for which application is made for insurance.

Veh. No.

Model Year Vehicle Make Body

Type/Model Full Vehicle Identification

Number

Orig. Mfg.

SeatingCap.

Principal Garaging Location

(city & state)

Radius

Opera-tion

AnnualMileage

Vehicle

(A) Anti-LockBrakes,

(B) Air Bagsor (C)

Wheelchair Lift

1

2

3

4

5

6

7

8

9

10

PURPOSE OF USE ABBREVIATION MUST BE SELECTED FOR EACH VEHICLEVeh.No.

Purpose of Use

Emergency Lights & Sirens

(Yes or No)

1

2

3

4

5

6

7

8

9

10

ALS Advanced Life Support

BLS Basic Life Support

BV Box Van

CP Cherry Picker

CV Cargo Van

F Flower Car

H Hearse

L Limo

LT Ladder Truck

MTA Medical Transportation

OR Off Road Auto

OV Other Van

PC Police Car

PPT Private Passenger Type

PT Pumper Truck

PU Pick Up

PV Passenger Van

RT Rescue Truck

SP Snow Plow

SS Street Sweeper

ST Semi-Trailer

T Truck

TA Transfer Ambulance

TR Trailer

TT Truck Tractor

UT Utility Trailer

WT Water Truck

Other, describe

PHYSICAL DAMAGE COVERAGE C Complete spaces below in detail for each respective auto/vehicle described above.Physical Damage Deductible Veh.

No. Date

Purchased Cost When Purchased

Current Stated Value (excluding permanently

attached equipment) Value of Permanently Attached Equipment

Total Stated Amount to be Insured Comprehensive

Spec. C of Loss Collision

1

2

3

4

5

6

7

8

9

10

18. Any loss payees? Yes No If yes, give name and address of mortgagee/loss payee for each vehicle

✑

✒

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19. Is the transportation of people your primary business? Yes No Are vehicles leased to drivers? Yes No

20. Do you transport physically disabled individuals? Yes No If yes, what percentage of the time

21. Is our policy to cover all vehicles owned, operated or under lease to applicant? Yes No If no, explain 22. Number of vehicles owned by you: Ambulances Wheel Chair Vans Priv. Pass. Types Fire Trucks

Rescue Trucks Police Cars Hearses Limos Other 23. Number of vehicles leased to you: Ambulances Wheel Chair Vans Priv. Pass. Types Fire Trucks

Rescue Trucks Police Cars Hearses Limos Other

LOSS EXPERIENCE Provide prior insurance carriers information for past full three years.Policy Term Premium Total Amount Claims Paid & Reserves

From To Insurance Company Name

No. of MotorPowered Vehicles

No. of Accidents Liab Phys Dam BI PD Comp/Coll Other

/ / / / / / / /

/ / / /

24. Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage

sought in this application? Yes No If yes, provide complete details

25. Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No If yes, explain

OPERATION INFORMATION C Complete only those sections relating to your operations.

AMBULANCE AND MEDICAL TRANSPORTATION VEHICLES 26. Do autos without lights and sirens have lifts, ramps or wheelchair tie downs? Yes No

If yes, show auto numbers from schedule

27. Do autos without lights and sirens have stretchers or gurneys? Yes No If yes, show auto numbers from schedule 28. How is gurney or wheelchair securely clamped for transportation?

29. Any autos operated 24 hours per day? Yes No If yes, show auto numbers from schedule

30. Is special driver training given? Yes No If yes, explain 31. What methods and qualifications are used for driver selection?

32. Are you the primary response unit for emergency (911) calls? Yes No 33. What percent of your ambulance dispatches are: Emergency (Code 3 or 4)? % Non-Emergency (Code 1 or 2)? % 34. What procedure is required of drivers as they approach a red light?

35. Is your operation privately owned? Yes No

36. If privately owned, are you affiliated with a taxi or other transportation company? Yes No If yes, explain

DRIVER TRAINING PROGRAMS37. Is operation part of a school curriculum? Yes No Is classroom instruction given? Yes No

38. Are all driver training autos equipped with dual brakes? Yes No If no, identify by auto number from schedule any that do not have dual brakes

39. Are autos equipped with any other dual controls? Yes No If yes, explain

40. Is there any personal use of the automobiles? Yes No

FIRE DEPARTMENTS41. Is your operation owned by a municipality? Yes No 42. What procedure is required of drivers as they approach a red light?

43. Is special driver training given? Yes No What methods are used for driver selection?

44. Are volunteers allowed to drive? Yes No If yes, is the same driver selection and special training used? Yes No

45. Do ladder truck drivers have special training? Yes No How many runs/calls are made per year per fire truck?

46. Is your operation volunteer? Yes No

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LAW ENFORCEMENT AGENCIES 49. Are officers given training in defensive driving? Yes No Are officers given training in high-speed and pursuit driving? Yes No 50. What procedure is required of drivers as they approach a red light?

SECURITY PATROLS51. Do vehicles operate 24 hours a day? Yes No Any special training? Yes No Are weapons carried? Yes No 52. Percentage of surveillance % Patrolling %

53. Additional comments:

FILING INFORMATION

54. Is an FHWA filing required? Yes No If yes, MC number

What authority do you have? Broker Common Contract 55. If you hold a Brokers license, identify name filed with FHWA, FHWA docket no. and receipts from brokerage operations

56. If you are an interstate regulated carrier, identify your registration or base state

57. Is an intrastate filing needed? Yes No If yes, show state and permit number

58. Show exact name and address in which permits are issued

59. Is MCS 90 endorsement needed? Yes No

60. Is our policy to cover all vehicles owned, operated or under lease to applicant? Yes No If no, explain

61. Do you enter Canada? Yes No Do you enter Mexico? Yes No If yes, where

62. Have you ever changed your operating name? Yes No Do you operate under any other name? Yes No

63. Do you operate as a subsidiary of another company? Yes No

64. Do you own or manage any other transportation operations that are not covered? Yes No

65. Do you lease your authority? Yes No Do you appoint agents or hire independent contractors to operate on your behalf? Yes No

66. Have you purchased, sold or applied for authority over the past 3 years? Yes No

67 Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.)? Yes No

68. Is evidence/certificate(s) of coverage required? Yes No 69. Please explain any "yes" answer to questions 62 through 68

70. Do you have agreements with other carriers for the interchange of vehicles or transportation of passengers? Yes No If yes, attach a copy of current agreements and complete the following: (a) With whom has such agreement(s) been made?

(b) Do the parties named in (a) carry automobile liability insurance? Yes No If yes, name of insurance company and limits of liability (Bodily Injury & Property Damage)

(c) Under whose permit does each of the parties to the agreement(s) operate?

(d) Is there a hold harmless in the agreement(s)? Yes No

71. Do you barter, hire or lease any vehicles? Yes No If yes, explain 72. Additional comments:

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FUNERAL DIRECTORS47. Are hearses also used as ambulances? Yes No If yes, what percent is ambulance

48. Are limousines used for other purposes? Yes No If yes, explain and show percentage

SELECTION OF LIMITS FOR UNINSURED/UNDERINSURED MOTORISTS COVERAGE (Virginia)

Virginia Insurance Code Section 38.2-2206 provides that policies of insurance which provide bodily injury or property damage liability insurance relating to the ownership, maintenance or use of a motor vehicle issued or delivered in the Commonwealth of Virginia must provide Uninsured motor vehicle coverage in limits not less than $25,000 because of bodily injury to or death of one person in any one accident and $50,000 because of bodily injury to or death of two or more persons in any one accident, and $20,000 because of injury to or destruction of property of others in any one accident. Such policies must also provide coverage for bodily injury or property damage caused by the operation or use of an Underinsured motor vehicle.

Under Virginia law, the limits of Uninsured/Underinsured motorist coverage must equal the limits of the liability insurance provided by your policy unless additional coverage is rejected by any one named insured. Therefore, if you purchase liability insurance in amounts greater than the state mandated minimum limits of $25,000/50,000/20,000, your Uninsured/Underinsured motorist coverage limits will equal these greater limits.

If you purchase liability insurance limits in excess of $25,000/50,000/20,000 you may reject the increased limits of Uninsured/Underinsured motorist coverage. If you reject the increased limits of Uninsured/Underinsured motorist coverage you must at a minimum purchase the state-mandated limits of $25,000/50,000/20,000. You may also choose to purchase Uninsured/Underinsured motorist coverage limits in excess of the state-mandated minimum amount yet less than your liability insurance limits. Ask your producer for coverage limits offered.

The rejection of the additional limits of Uninsured/Underinsured motorist insurance by any one named insured is binding on all insureds under such policy.

In accordance with the Virginia law, the undersigned insured (and each of them):

(Applicable item marked X)

Selects Uninsured/Underinsured motor vehicle coverage limits in the amount of $25,000/50,000/20,000. These are the lowest coverage limits which may be purchased by law. Selects Uninsured/Underinsured motor vehicle coverage limits which lower are than the liability limits under the policy but higher than the state-mandated minimum limits. Selected limits for Uninsured/Underinsured motorist coverage are:

(Enter limits if a separate limit of liability applies) $ Bodily Injury each person $ Bodily Injury each accident $ Property Damage each accident

(Enter limit if a single limit of liability applies) $ Each accident

MEDICAL EXPENSE AND INCOME LOSS BENEFITS SELECTION

Medical Expense Benefits - Choose one:

RejectAccept If accepting, choose one: $500 $1000 $2000 $5000

Income Loss Benefits - Choose one:

RejectAccept

I have indicated my choice above ("X" indicates my choice):

Signature of Insured Signature of Insured

Date Policy Number

(Until you advise us otherwise in writing, your choices, as indicated above, will continue regardless of any addition or change in Auto coverage on your current policy or addition of any Scheduled Autos.)

SIGNATURE IS ALSO REQUIRED ON LAST PAGE OF APPLICATION

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MUST BE SIGNED BY THE APPLICANT PERSONALLY

No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may not accept any funds for the Company, and may not modify or interpret the terms of the policy.

The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false, the Company may rescind any policy or subsequent renewal it may issue.

If any jurisdiction in which the Applicant intends to operate or the Interstate Commerce Commission requires a special endorsement to be attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that endorsement.

The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect.

The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation.

The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).

Will premium be financed? Yes No If yes, with whom

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

Witness Applicant's Signature Date

TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE

Is this direct business to your office? If not, explain

Is this new business to your office? If not, how long have you had the account?

How long have you known applicant?

REQUEST TO COMPANY GENERAL AGENT:

Please quote Please bind at earliest possible date and issue policy

Please issue policy effective Coverage was bound by (Time and Date Bound by General Agent) (Name of Person in Company General Agency's Office Binding Coverage)

Applicant's Representative's Name and Address Phone No.

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